Case SeriesEarly Stone Manipulation in Urinary Tract Infection Associatedwith Obstructing Nephrolithiasis

Megan L. Swonke, Ali M. Mahmoud, Elias J. Farran, Tamer J. Dafashy , Preston S. Kerr ,Christopher D. Kosarek , and Joseph Sonstein

Division of Urology, Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA

Correspondence should be addressed to Joseph Sonstein; josonste@utmb.edu

Received 10 July 2018; Accepted 6 November 2018; Published 25 November 2018

Academic Editor: Ferdinando Fusco

Copyright © 2018 Megan L. Swonke et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

A urinary tract infection (UTI) and sepsis secondary to an obstructing stone are one of the few true urological emergencies. Theaccepted management of infected ureteral stones includes emergent decompression of the collecting system as well as antibiotictherapy. Despite this, no consensus guidelines clarify the optimal time to undergo definitive stone management following decom-pression. Historically, our institution has performed ureteroscopy with laser lithotripsy (URS-LL) treatment at least 1 to 2 weeksafter decompression to allow for clinical improvement and completion of an antibiotic course. In this case series, we retrospectivelyreview four cases in which patients had a documented UTI secondary to an obstructive ureteral stone. The patients underwenturgent decompression and, based on labs and clinical improvement, were subsequently treatedwithURS-LL.Thepresented patientsreceived URS-LL within 5 days of decompression and antibiotics. The patients had no sepsis related postoperative complicationsfrom the accelerated course of treatment, resulting in discharge within 2 days following URS-LL.We provide a detailed examinationof each patient presentation to describe our institution’s experience with treating infected kidney stones within days of urgentdecompression in order to question the previous standard of treating an infected kidney stone with a more delayed intervention.

1. Introduction

Approximately 1 out of every 11 people in the United Statesreports a history of kidney stones, marking a significantincrease in stone disease over the prior 15 years [1, 2]. Treat-ment of nephrolithiasis over the past decades has shifted awayfrom inpatient settings and open procedures to outpatientenvironments and less invasive options, such as endoscopy[3]. With increasing prevalence, urolithiasis is estimated topose a $1.24 billion economic burden per year by 2030 [4].

It is understood that not all patients with stone diseaserequire urgent intervention [5]; however, patients presentingwith a urinary tract infection (UTI) in the setting of ureteralstone obstruction require urgent surgical decompression inorder to avoid serious complication, including mortality[6]. Current American Urological Associated (AUA) andEuropean Association of Urology (EAU) guidelines suggestthat active UTI with stone obstruction be drained witha nephrostomy tube or ureteral stent before treatment of

stone in order to allow for the penetration of antibioticsand drainage of infected urine before definitive treatmentof the stone [7, 8]. While the literature discusses differentmethods of decompression of the collecting system [9] as wellas factors that influence the timing of initial intervention fordecompression [10], there are no evidence-based guidelinesto suggest when a complicated stone should be treated. Atour institution, the typical standard has been to wait 1-2weeks after surgical decompression and antibiotics to treat aninfected kidney stone. In this study, we review four cases inwhich patients with UTI in the setting of obstructing stonesreceive definitive treatment within days of administeringantibiotics and decompression with stenting.

2. Materials and Methods

We retrospectively reviewed four cases in which patients hada UTI with concomitant upper tract obstruction secondaryto urolithiasis. In each patient, the diagnosis was confirmed

HindawiCase Reports in UrologyVolume 2018, Article ID 2303492, 6 pageshttps://doi.org/10.1155/2018/2303492

2 Case Reports in Urology

by noncontrast computed tomography (CT) scan of theabdomen and pelvis. Per established guidelines [7], emergentstenting was performed, followed by various IV antibiotictreatments. Based on labs and clinical improvement, patientswere treated with ureteroscopy with laser lithotripsy (URS-LL). The timing of URS-LL, the length of hospital stay,and postoperative complications were documented. All caseswere performed between February 2015 and October 2017.

3. Case Presentations

3.1. Case 1. A 62-year-old female with a past medical historyof hypertension presented to the emergency departmentwith worsening left flank pain associated with nausea andsubjective fevers. Physical examination findings included leftlower quadrant tenderness and left sided costovertebral angletenderness. The patient had no history of nephrolithiasis.

The patient was afebrile, but her initial vital signs weresignificant for hypertension (182/95)/MAP (124), tachycardia(109 beats per minute), and tachypnea (20 breaths perminute). The patient's complete blood count (CBC) andserum chemistry panel showed a leukocytosis of 16,500/𝜇Land a creatinine of 1.36 mg/dL. Urinalysis found 44 whiteblood cells (WBCs) and 16 red blood cells (RBCs) per high-power field (HPF), with positive leukocyte esterase (500/𝜇L),negative nitrites, and nobacteria, and initial urine culture wascontaminated. Initial CT scan showed obstructing left sidedstones (1 cm calcified stone within the proximal left ureterand a 2.2 cm stone below the ureteropelvic junction) causinghydronephrosis.

The patient was then started on levofloxacin at the timeof admission and subsequently underwent a left ureteralstent placement. During stent placement, purulent dischargewas noted after cannulation with a guidewire. Postoperativecourse was unremarkable. The urine culture showed nogrowth or presence of bacteria after 24 hours. Considering thepatient was afebrile, hemodynamically stable, and labs werewithin normal limits, the patient underwent URS-LL oneday following stent placement. The duration of the procedurewas 94 minutes. An access sheath was placed and a flexibleureteroscope was advanced into the kidney. A single stonewas encountered in the lower pole of the kidney and wasfragmented to dust then extracted with a zero-tip basket. Fol-lowing removal of the stones, the patient clinically improvedand was discharged the next day with a stent in place.

3.2. Case 2. A 49-year-old female with a past medical historyof a solitary right kidney presented with right lower quadrantpain associated with nausea, vomiting, decreased urination,and dysuria. Physical exam findings included right lowerquadrant tenderness and right costovertebral angle tender-ness. The patient had no history of stones.

During the initial evaluation, the patient's vital signs weresignificant for hypotension (77/46), tachycardia (117 beats permin), tachypnea (22 breaths per min). She was afebrile; how-ever, had leukocytosis of 24,190/𝜇L, creatinine of 3.90mg/dL,and lactic acid of 7.49 mg/dL. There was concern for sepsisdue to a sequential (sepsis related) organ failure assessment(SOFA) score >2 [11]. Urinalysis found 30WBCs and 6 RBCs

Figure 1: Axial CT scan of the abdomen and pelvis without contrastrevealed an atrophic left kidney and a 4mmstone (arrowhead) in theright ureterovesical junction causing mild hydroureteronephrosiswith findings suggestive of pyelonephritis.

per HPF, positive leukocyte esterase, and negative nitrites.Urine culture grew Klebsiella pneumoniae. Initial CT scanshowed an atrophic left kidney and a 4 mm stone in the rightureterovesical junction causing mild hydroureteronephrosiswith findings suggestive of pyelonephritis (Figure 1).

The patient underwent an emergent cystoscopy with rightureteral stent placement and was started on piperacillin-tazobactam. Intraoperatively, purulent discharge emittedfrom the right ureteral orifice after cannulation with aguidewire. Her postoperative course was complicated by per-sistent hypotension requiring vasopressors. Blood culturesrevealed Klebsiella and antibiotics were tailored accordingly.

Three days following decompression and continued IVantibiotics, repeat blood and urine cultures were negative forbacteria. On the fifth day, with no obvious signs or symptomsof persistent infection, the patient underwent a URS-LLand right ureteral stent placement with a string. A rigidureteroscope was introduced into the ureter and a stone wasencountered in the distal ureter. Laser lithotripsy was per-formed, and the stone was obliterated into small fragmentswhichwere extracted with awire basket. Laser lithotripsy wasperformed instead of a simple extraction to safely extract thestone without causing damage to the ureter. Subsequently, anaccess sheath was then placed and a flexible ureteroscope wasadvanced into the kidney. Randall plaques were encounteredin the upper pole and were removed using laser lithotripsy.The duration of the procedure was 108 minutes. FollowingURS-LL, the patient recovered without complications andwas discharged on the same day with a completion course ofPO antibiotics. The patient was at high risk to be lost to followup, so was instructed to pull the string to remove the stenton postoperative day 3. Given what was essentially a solitarykidney and the patient’s social circumstances, the risk of aretained ureteral stent in this setting outweighed the risks ofpremature stent removal; thus the stent was left attached tothe string to facilitate self-removal of the stent.

3.3. Case 3. A 59-year-old female with no significant pastmedical history presented to the emergency department with

Case Reports in Urology 3

Figure 2: Coronal CT scan of the abdomen and pelvis with contrastrevealed a 6 mm obstructing right proximal ureteral stone (notshown in image) causing mild hydronephrosis and a 2 cm leftinferior pole staghorn calculus causing calyceal dilatation (arrow).

acute onset right flank pain radiating to the right lowerquadrant. The pain was described as stabbing and constantand associated with nausea and vomiting. She had no priorhistory of nephrolithiasis. The patient’s CBC and serumchemistry were within normal limits. Urinalysis was positivefor nitrite, leukocyte esterase (500/𝜇L), 27 WBC per HPF, 23RBC per HPF, and moderate bacteria. Urine culture revealedthe presence of >100,000 CFU/mL Escherichia coli. InitialCT scan showed a 6 mm obstructing right proximal ureteralstone causing mild hydronephrosis and a 2 cm left inferiorpole partial staghorn calculus causing calyceal dilatation(Figure 2).

The patient was then started on IV levofloxacin andunderwent bilateral ureteral stent placement the followingday without complication. Urine culture collected duringstent placement showed resolution of bacteriuria. Five daysafter stent placement and continued antibiotic therapy, thepatient underwent bilateral URS-LL, complicated by leftureteral perforation upon guidewire placement. The per-foration occurred due to a technical error where the stiffend of the PTFE wire was advanced up the ureter and wasseen perforating the ureter on fluoroscopy. The wire wasremoved and then advanced correctly. An access sheath wasplaced past the perforation and a flexible ureteroscope wasadvanced. One stone was encountered in the left inferiorpole of the kidney and another was encountered in the rightproximal ureter. They were both fragmented then extractedwith a zero-tip basket. The duration of the procedure was60 minutes. The patient was discharged after two days ofhospitalization. The stents were removed in clinic three weekspostoperatively without complication.

3.4. Case 4. A 62-year-old female with a past medical historyof hypertension, poorly controlled diabetes, and nephrolithi-asis presented to our hospital’s emergency department threedays after receiving a diagnosis of UTI with multiple nonob-structive renal stones. The patient was found to have rightsided abdominal pain radiating to her right flank with fevers,nausea and vomiting, and endorsed dysuria. CBC and serum

chemistry panel showed a leukocytosis of 13,740/𝜇L, andcreatinine of 1.06 mg/dL. Urinalysis was positive for ketones,proteinuria, urobilin, nitrite, leukocyte esterase, 146 RBC perHPF, over 182 WBC per HPF, and many bacteria. Urineculture was positive for Escherichia coli. CT scan performedat our institution showed an 8mm right obstructive proximalureteral stone as well as bilateral nonobstructive stones(Figure 3).

The patient was given ceftriaxone and underwent rightureteral stent placement. The patient tolerated the procedurewell. Intraoperative urine culture was positive for E. coliand she was started on piperacillin-tazobactam. Four daysafter decompression, she underwent uncomplicated URS-LL.A rigid cystoscope was introduced into the bladder and aflexible grasper was used to grasp and remove the retainedureteral stent. A ureteral access sheath was placed overa guidewire before a flexible ureteroscope was introducedinto the ureter through the access sheath. An 8 mm stonewas encountered in an interpolar calyx. Laser lithotripsywas performed to obliterate the stone into small fragmentswhich were then extracted with a wire basket. No stent wasplaced after procedure. The duration of the procedure was43 minutes. Postoperative course was uneventful, and thepatient was discharged later that day.

4. Discussion

UTI with concomitant obstructive nephrolithiasis is consid-ered a urologic emergency due to the risk of sepsis, renalloss, and even death. It is well understood that the acceptedmanagement of infected ureteral stones entails emergentdecompression of the collecting system and antibiotics [7].Borofsky et al. [5] attested the mortality rate to be higherin patients who did not receive surgical decompressioncompared to those who received intervention. Neither percu-taneous nephrostomy (PCN) nor ureteral stent proved to bea superior draining technique in regard to clinical outcomes[6]. Although controversial, both are currently accepted asthe standard of care [6, 9, 10, 12]. However, the optimal timeto treat these stones following decompression and empiricantibiotic treatment remains unclear.

Current literature highlights the risk of sepsis followingmanipulation of ureteral stones in the background of infec-tion [13]. The AUA encourages physicians to delay stonetreatment, but does not provide an optimal time to treat theinfected stones, only concluding that stone removal shouldbe delayed until infection has resolved and the patient hasbeen treated with an appropriate course of antibiotic therapy[7]. The EAU also reiterates that manipulation should bepostponed until the infection has cleared, and the antibioticcourse has been completed [8].

Only one published randomized control trial involving107 patients has explored immediate ureteroscopic manage-ment in the setting of sepsis versus PCN for decompression[14]. The trial concluded the length of hospital stay to belonger in the emergent retrograde ureteroscopicmanagementgroup compared to the PCN group [14]. In addition, the trialconcluded a higher analgesic requirement in the emergentretrograde ureteroscopic management group compared to

4 Case Reports in Urology

(a) (b)

Figure 3: Axial (a) and coronal (b) CT scans of the abdomen and pelvis without contrast revealed an 8mm right obstructive proximal ureteralstone ((a) arrowhead) causing hydroureter and hydronephrosis ((b) arrow).

the PCN group [14]. Although patients in the emergent ret-rograde ureteroscopic management group had a significantlyhigher incidence of fever, the trial did not find a statisticaldifference in the groups in regard to level of leukocytosis,time to normalization of WBC (days), time to normalizationof body temperature (days), C-reactive protein (mg/dl), C-reactive protein reduction over 25%(days), procalcitonin(ng/ml), and complications rate [14]. The trial advocatedfor immediate URS-LL when given antibiotics to adequatelytreat obstructive pyelonephritis [14]. These findings provideadditional support for our results, and suggest with properclinical judgement, URS-LL can be performed within days ofsystem decompression without risk of harm to patients.

Our series presents four patients with UTI and obstruc-tive urolithiasis in whichURS-LLwas successfully performedwithin days of antibiotic administration and decompression(Table 1). The common denominator for these four patientswho received early treatment is that they were identified aspatients who would be at high risk for being lost to follow upwith a retained stent based on their lack of access to health-care resources. This risk of retained stent with its potentialcomplications was considered in the decision making as towhether tomanage these stones during their initial admissionfor infected stone. There is no current guideline regardingthe appropriate time for stone treatment after emergent stentplacement in the context of an infected stone. All patientswere appropriately counseled regarding the inherent risksand potential complications of the procedure and given athorough informed consent regarding surgery. The patientsunderstood the risks and were amenable to this treatment.

The patients in all four cases presented with symptomsof a UTI secondary to urolithiasis as confirmed by CTscan. Additionally, the patient in Case 2 presented withsepsis consistent with the Third International ConsensusDefinitions for Sepsis and Septic Shock. Her SOFA score was>2, including a creatinine level >3.5 mg/dL and hypotensionrequiring the administration of a vasopressor [11]. In Case2, the patient’s blood cultures revealed Klebsiella bacteremia,

and in Cases 3 and 4 the patient's urine cultures were positiveforE. coli. However, the patient inCase 1 had negative culturesat the time of presentation, potentially due to immediateantibiotic dosing at admission. We recognize that in thissetting cultures may not always be positive for bacteria;a negative culture does not necessarily exclude infection,particularly a midstream urine catch, or if antibiotics areadministered prior to culture causing sterilization within afew hours [5, 15–17]. Empiric antibiotic therapy consisted ofbroad-spectrum antibiotics, but was adjusted according tocultures [18]. The urine culture in Case 1 was contaminated;therefore, we were unable to tailor our antibiotic choice andlevofloxacin was continued based on clinical response. URS-LL was performed when the patient exhibited improvementwith decompression and antibiotics. This occurred withinone day of decompression.

The highest concern of manipulating an infected stone isthe risk of sepsis postoperatively. The four patients had nosigns of sepsis postoperatively and were all candidates fordischarge on the same day of the procedure with continuedantibiotics. Case 3 was kept for an additional two days forpain management. In addition, this patient experienced acomplication of wire perforation during initial safety wireplacement. We consider this due to technical error, ratherthan a complication related to her infection.

Our case series has demonstrated successful URS-LL ofobstructing stones in the setting of UTIs within days of stent-ing, several days shorter than our typical institutional stan-dard. If similar outcomes can be replicated in larger prospec-tive randomized controlled studies, treatment standards mayclarify a shorter period before definitive surgical interventionin an attempt to optimize patient care and reduce costs.

5. Conclusion

Upon reviewing these four cases at our institution, we didnot observe any significant adverse outcomes related to sepsisin treating patients within 5 days of decompression when

Case Reports in Urology 5

Table1:Com

parin

gCa

ses1,2,3,and

4.

Cases

WBC

Creatinine

UA:W

BC(per

hfu),

leuk

ocytee

sterase,

nitrite

sUrine

Cultu

reObstructin

gSton

esize

Daysb

efore

URS

-LLaft

erde

compres-

sion

Com

plications

after

URS

-LL

Daysb

efore

discha

rge

after

URS

-LL

Case1

16,500

/𝜇L

1.36𝜇mol/L

44,+

,-Con

taminated

1cm

and2.2

cm1

Non

e1

Case2

24,19

0/𝜇L

3.90𝜇mol/L

30,+

,-Klebsiella

pneumoniae

4mm

5Non

e0(sam

eday)

Case3

5,700/𝜇L

0.73𝜇mol/L

27,+

,+Escherich

iacoli

6mm

(right)

and2cm

(left)

5Leftureteral

perfo

ratio

n2

Case4

13,74

0/𝜇L

1.06𝜇mol/L

182,+,

+Escherich

iacoli

8mm

4Non

e0(sam

eday)

6 Case Reports in Urology

compared to the more conservative approach of withholdingtreatment for 1 to 2 weeks. It is important to note our caseseries is limited by the small number of cases reviewed andfurther studies are needed to clarify the hypothesis generatedand the appropriate guidelines regarding the timeline oftreatment. Physician awareness should be increased on thefeasibility of performing accelerated stone intervention in thissetting to optimize patient care.

Ethical Approval

Procedures were performed according to the ethical stan-dards of the Declaration of Helsinki.

Consent

Written informed consent to publish was obtained from thepatients prior to submission of this manuscript.

Disclosure

There is no financial support for this case report.

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this article.

References

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[4] J. A. Antonelli, N. M. Maalouf, M. S. Pearle, and Y. Lotan,“Use of the National Health and Nutrition Examination Surveyto calculate the impact of obesity and diabetes on cost andprevalence of urolithiasis in 2030,” European Urology, vol. 66,no. 4, pp. 724–729, 2014.

[5] M. S. Borofsky, D. Walter, O. Shah, D. S. Goldfarb, A. C. Mues,and D. V. Makarov, “Surgical decompression is associated withdecreased mortality in patients with sepsis and ureteral calculi,”The Journal of Urology, vol. 189, no. 3, pp. 946–951, 2013.

[6] M. S. Pearle,H. L. Pierce, G. L. Miller et al., “Optimal method ofurgent decompression of the collecting system for obstructionand infection due to ureteral calculi,”The Journal ofUrology, vol.160, no. 4, pp. 1260–1264, 1998.

[7] D. Assimos, A. Krambeck, N. L. Miller et al., “Surgical Man-agement of Stones: American Urological Association/Endo-urological Society Guideline, PART I,” The Journal of Urology,vol. 196, no. 4, pp. 1153–1160, 2016.

[8] H. G. Tiselius, D. Ackermann, P. Alken, C. Buck, P. Conort, andM.Gallucci, “Guidelines on urolithiasis,” EuropeanUrology, vol.40, no. 4, pp. 362–371, 2001.

[9] M. S. Elsheemy, A. M. Shouman, A. I. Shoukry et al., “Uretericstents vs percutaneousnephrostomy for initial urinary drainagein children with obstructive anuria and acute renal failuredue to ureteric calculi: A prospective, randomised study,” BJUInternational, vol. 115, no. 3, pp. 473–479, 2015.

[10] S. Ramsey, A. Robertson, M. J. Ablett, R. N. Meddings, G.W. Hollins, and B. Little, “Evidence-based drainage of infectedhydronephrosis secondary to ureteric calculi,” Journal of Endo-urology, vol. 24, no. 2, pp. 185–189, 2010.

[11] M. Singer, C. S. Deutschman, C. Seymour et al., “The thirdinternational consensus definitions for sepsis and septic shock(sepsis-3),” Journal of the AmericanMedical Association, vol. 315,no. 8, pp. 801–810, 2016.

[12] M. F. Lynch, K. M. Anson, and U. Patel, “Current opinionamongst radiologists and urologists in the UK on percutaneousnephrostomy and ureteric stent insertion for acute renal unob-struction: Results of a postal survey,” BJU International, vol. 98,no. 6, pp. 1143-1144, 2006.

[13] P. N. Rao, D. A. Dube, N. C.Weightman, B. A. Oppenheim, andJ. Morris, “Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract,”The Journalof Urology, vol. 146, no. 4, pp. 955–960, 1991.

[14] C.-J.Wang, C.-S. Hsu, H.-W. Chen, C.-H. Chang, and P.-C. Tsai,“Percutaneous nephrostomy versus ureteroscopic managementof sepsis associated with ureteral stone impaction: a random-ized controlled trial,” Urolithiasis, vol. 44, no. 5, pp. 415–419,2016.

[15] P.D. Brown, “Management of urinary tract infections associatedwith nephrolithiasis,” Current Infectious Disease Reports, vol. 12,no. 6, pp. 450–454, 2010.

[16] K.-H. Bichler, E. Eipper, K. Naber, V. Braun, R. Zimmermann,and S. Lahme, “Urinary infection stones,” International Journalof Antimicrobial Agents, vol. 19, no. 6, pp. 488–498, 2002.

[17] T.M. Hooton andW. E. Stamm, “Management of acute uncom-plicated urinary tract infection in adults,” Medical Clinics ofNorth America, vol. 75, no. 2, pp. 339–357, 1991.

[18] T. Marien, A. Y. Mass, and O. Shah, “Antimicrobial resistancepatterns in cases of obstructive pyelonephritis secondary tostones,” Urology, vol. 85, no. 1, pp. 64–68, 2015.

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